Express Scripts (Evernorth / Cigna)
PBM standard commercial template (National Preferred Formulary) · updated August 8, 2026
Coverage right now
- Foundayo™ (orforglipron) Preferred
- Saxenda® (liraglutide) Non preferred
- Wegovy® (semaglutide injection) Preferred
- Wegovy® tablets (oral semaglutide) Preferred
- Zepbound® (tirzepatide) Preferred
Kept both Wegovy and Zepbound single-dose pens preferred through the 2025 upheaval. 2026 NPF: Zepbound pens, Wegovy (pens, HD, tablets), and Foundayo all preferred — but Zepbound KwikPens and vials are excluded (device-level steering). PA criteria run through the Cigna National Formulary policy cnf_684.
Drug status
| Drug | Status | Detail | Confidence |
|---|---|---|---|
| Zepbound® (tirzepatide) | Preferred from Jan 1, 2026 | Single-dose pens preferred on the 2026 National Preferred Formulary. KwikPens and vials EXCLUDED (alternatives: Zepbound pens, Wegovy, Foundayo, liraglutide). source | high |
| Wegovy® (semaglutide injection) | Preferred from Jan 1, 2026 | Pens and HD preferred. source | high |
| Wegovy® tablets (oral semaglutide) | Preferred from Jan 5, 2026 | Wegovy tablets preferred on the 2026 NPF. source | high |
| Foundayo™ (orforglipron) | Preferred from Jul 1, 2026 | Listed preferred in the 07/01/2026 NPF — one of the fastest adds of the new oral. source | high |
| Saxenda® (liraglutide) | Non preferred from Jan 1, 2026 | Brand not preferred; generic liraglutide is the preferred agent. source | medium |
What preferred, covered and exception only mean
- Preferred
- On the formulary at the plan's best tier for this class. Usually still needs prior authorization — preferred is not the same as automatic.
- Covered
- On the formulary, but not the plan's first choice for this class. Often a higher copay tier than a preferred drug.
- Non preferred
- On the formulary at a disadvantaged tier, or reachable only after trying a preferred drug first.
- Exception only
- Not routinely covered. Obtainable only through a formulary-exception request that meets the plan's published criteria.
- Excluded
- Not on the formulary at all. A benefit exclusion is a different fight from a PA denial and is appealed differently.
- Varies
- The payer's own documents differ by plan or line of business, so a single answer here would be wrong.
- Unknown
- Not yet verified against a primary document. Recorded as absent rather than guessed.
- N/A
- Not applicable to this payer.
Prior authorization criteria
high- PA required
- Yes, where the plan covers weight loss (EncircleRx adds employer-level eligibility management; participating plans cap member GLP-1 cost at <= $200/month).
- Initial BMI
- Baseline BMI >= 30, OR baseline BMI >= 27 with >= 1 weight-related comorbidity. Pediatric (12-17, Wegovy/liraglutide): BMI >= 95th percentile. Age >= 18 for Zepbound/Foundayo.
- Comorbidities
- Hypertension, T2D, dyslipidemia, OSA, cardiovascular disease, knee osteoarthritis, asthma, COPD, MASLD/NAFLD, PCOS, or coronary artery disease — the broadest published list among major PBMs.
- Lifestyle requirement
- Trial of behavioral modification and dietary restriction for at least 3 months, AND concomitant use with behavior modification and reduced-calorie diet.
- Initial authorization
- 8 (Wegovy, Zepbound, Foundayo) · 4 (liraglutide/Saxenda)
- Reauthorization
- Lost >= 5% of baseline body weight (>= 4% liraglutide; pediatric: BMI reduction >= 1%). Baseline = before any GLP-1. Reauthorization lasts 1 year.
- Step therapy
- None in the PA policy; steering happens at device level via formulary exclusions (KwikPen/vial excluded).
- Quantity limits
- Zepbound: 2 mL (4 pens or vials) per 28 days retail; 6 mL (12) per 84 days home delivery — no overrides (policy cnf_840).
Primary criteria document:static.cigna.com
Exceptions and appeals
- Appeal deadline
- 180 days
- Deadline detail
- 180 days from receipt of the adverse determination (Level 2: 90 days).
- Exception route
- Prescriber ePA via esrx.com/PA, ExpressPAth, CoverMyMeds, or Surescripts. Clinical appeals: Express Scripts, Attn: Clinical Appeals Department, P.O. Box 66588, St. Louis, MO 63166-6588 · fax 877-852-4070 · urgent 800-753-2851.
- Turnaround
- ESI states nearly all coverage reviews complete within two days of complete information; ePA can return in minutes. Regulatory frame: 72 hours urgent, 15 days pre-service.
- Where
- Express Scripts, Attn: Clinical Appeals Department, P.O. Box 66588, St. Louis, MO 63166-6588 · fax 877-852-4070
Source:hr.jhu.edu
Dated changes
Criteria cited are Cigna National Formulary coverage policies (cnf_684, rev. 4/15/2026) used with ESI-administered Cigna business; the ESI NPF standard tracks these closely but self-funded clients customize. A widely-indexed secondary source claims Wegovy is excluded from the 2026 NPF — contradicted by ESI's own formulary PDF. Trust the primary document.
These are each payer's standard template. Employer plans customize them, so the same PBM can cover a drug for one employer and exclude it for another — a status here is a starting point, not your plan. A benefit exclusion is also a different fight from a PA denial. Always request your own plan's criteria in writing; you are entitled to them.